Clinical Governance
Annual Report
September 2009
Helen Robbins, Head of Clinical Governance and Risk Management
Correspondence to:
Head of Clinical Governance and Risk Management: /

Name:Helen Robbins

Address:181 Union Street,Aberdeen

Telephone No: 01224 224909

Produced by the Clinical Governance & Risk Management Unit, NHS Grampian,

St Martin’s House, 181 Union Street, Aberdeen AB11 6BB Tel: (01224) 224909

CONTENTS

SECTION 1

INTRODUCTION...... 2

SECTION 2

CLINICAL GOVERNANCE FRAMEWORK...... 3

SECTION 3

QUALITY IMPROVEMENT...... 11

SECTION 4

PATIENT EXPERIENCE...... 15

SECTION 5

CONCLUSION, challenges and risks...... 18

REFERENCES...... 20

DISTRIBUTION LIST ...... 21

SECTION 1
Introduction
“Clinical governance is the system through which NHS organisations are accountable for continuously monitoring and improving the quality of their care and services and safeguarding high standards of care and services.”
NHS Quality Improvement Scotland (2005)
NHS Grampian has developed the system so that excellent care is further developed and delivered, ensuring it is effective and safer for patients and staff. It is about having the right systems and processes in place to understand how and why we do things, to assess whether they work and what is required to ensure they are sustainable. It is also about learning and sharing information so that duplication is avoided and work already undertaken informs future developments for improving care. Our aim is to ensure that we use this approach to continually improve the experience of patients and their carers.
SECTION 2
Clinical Governance Framework
2.1 / Clinical Governance Framework
The Statement of Intent for Clinical Governance states that Clinical Governance within NHS Grampian will be the framework as predicated on the belief that clinical governance will:
  • be undertaken in partnership between senior managers and health professionals.
  • be a key driver for continuously improving the quality of patient care, the health of local communities and maintaining the highest standards of professional conduct and clinical practice.
  • facilitate the recognition and replication of good clinical practice.
  • support an open and transparent culture, underpinned by a commitment to engage staff, patients, partners and other stakeholders in the improvement and development of our clinical services.

2.2 / Overview of Committee
The Clinical Governance Committee has overseen the development of the clinical governance arrangements within NHS Grampian and has assured the Board that these structures are operating effectively and action has been taken to address any areas of concern. The Committee has met 4 times in 2008, with the required quorum. The clinical governance structure has been adapted to include a specific child health group, reflecting the redesign of the management arrangements.
The Clinical Governance Committee has supported Clinical Governance mechanisms through the:
  1. Committeeworkplan, (renaming this an Assurance Plan),
  2. Assurance framework and
  3. Exception reporting
The assurance plan has been considered by the Committee and has been updated and approved by the Clinical Governance Committee in February 2009.
The Assurance Framework Group has been updating the Assurance framework for NHS Grampian and the role of the Clinical Governance Committee has been taken into account.
Matters of a significant or serious nature have been reported directly to the Clinical Governance Committee via sector reports. Sector reports also detail areas of achievement or good practice. The reports are considered in detail at each Committee. The reporting template has been adapted several times to ensure it is fit for purpose and now includes a section to report on Ombudsman cases. Additional items were requested at the Committee meeting in November 2008on:
1.Cleanliness Champion, progress report
2.Quality of Record keeping and
3.Management of Deep Vein Thrombosis
Quorum:
A minimum of 3 Non-Executive Committee members has been achieved for each Committee meeting.
Meetings:
Meetings have been held quarterly with dates agreed and set in advance for the year.
Agenda setting meetings have been held at least 2 weeks prior to the meeting and Committee papers have been issued one week in advance.
Minutes and Reports:
The business of the Committee has been recorded in a formal minute. The approved minutes are included on the NHSG Board and Sector Clinical Governance Groups agendas.
The Committee provide the Board with a written formal report following each Committee meeting.
Evaluation of the Committee fulfilling its Role and Remit
  • Provide a strategic oversight of systems and procedures for Clinical Governance arrangements across NHS Grampian.
The Committee has ensured that the system for clinical governance has been maintained. The development sessions of the Committee have been used to explore how the system and procedures might be improved. The areas covered have included discussing how the change and improvement programmes take account of the need to provide assurance on clinical aspects of their work.
  • Support and monitor the implementation of dynamic clinical governance arrangements across NHS Grampian.
The Committee has also taken account of the changing structure of NHS Grampian thus incorporating the revised arrangements for clinical governance in children’s services.
The governance arrangements around Managed Clinical Networks has been strengthened as part of the formal review into the MCNs. The subsequent framework now includes the requirement of a quality assurance section and reporting to the Clinical Governance Committee.
The Committee has overseen a review of the sector clinical governance arrangements. This is detailed in the section “Clinical Governance Evaluation Plan”
  • Report regularly to the NHS Board on the progress and effectiveness of the Clinical Governance Arrangements, highlighting any areas of concern.
The Committee took part in a Grampian wide Committee evaluation exercise led by the internal Auditors (PriceWaterhouse Coopers). The collated results were then reported in a single report to the Board.
  • The Committee has also reported to the Board via the Statement of Internal Control to inform and provide assurance to the NHS Board that action is being taken to address areas identified as a significant clinical risk.
The Committee has reported to the Board via the Statement of Internal Control. The Committee has also reported to the Board after every Committee meeting. The following areas have been reported to the Board:
Healthcare Acquired Infection
Child Protection
Acute service activity
  • Notify the NHS Grampian Performance Governance Committee (PGC) of areas of significant clinical risk for inclusion in the performance monitoring systems of the organisation.
The Committee has reported risks to the Performance Governance Committee after every Committee meeting. The PGC has then reported collated risks to the NHSG Board. Items reported to PGC have included:
Healthcare Acquired Infection
  • Provide an Annual Report on Clinical Governance detailing progress against the agreed Clinical Governance Committee WorkPlan thus providing appropriate information for inclusion in the NHS Grampian Annual Statement of Internal Control.
An Annual reports have been provided in the previous year:
The Clinical Governance Forum provided an Annual Report 2008 to the Clinical Governance Committee on the 29th August 2008 and the Clinical Governance & Risk Management Unit provided an Annual Report 2007-2008 to the Committee on the 29th August 2008.
  • Promote a fair and just culture to encourage continuous quality improvement within all NHS Grampian’s clinical services.
The Committee has encouraged the sharing and reporting of continuous improvement for example the sector reports include a section on reporting good practice. The Committee has also invited a number of different areas of the service (e.g. maternity and mental health) to attend and describe the current quality priorities for that service. This process has attempted to promote the working of the Committee more widely and to allow services to have a dialogue with the Committee. The Committee development session that explored clinical governance for improvement programmes demonstrated a commitment to supporting continuous improvement. The Clinical Governance & Risk Management Unit staff are now more closely involved in supporting improvement activities particularly around the area of risk assessment and evaluation. These areas are then considered within sector clinical governance groups and areas reported to the Committee as appropriate. .
2.3 / Clinical Governance Groups
Sectors have maintained their own clinical governance groups according to their agreed role and remits and clinical governance Frameworks. Clinical Governance Leads have functioned within each sector. Clinical Governance Coordinators have also functioned in each sector, with some movements of staffing.
Considerable discussions have taken place about a Clinical Governance Coordinator role for Child services but it has not been possible to implement this to date.
The sector groups have all reported to the Committee for each meeting submitting a sector report.
The sector groups were evaluated as part of an evaluation of the overall sector clinical governance working and a report has been produced. This work is described in detail in section 2.8.
2.4 / Clinical Governance Statement of Intent
The Clinical Governance Committee Role, Remit and Membership paperwas reviewed in October 2008.
The Clinical Governance Committee Statement of Intent was reviewed in March 2008.
2.5 / NHS Quality Improvement Scotland Clinical Governance and Risk Management Standards Report
NHS Grampian was reviewed against the Clinical Governance and Risk Management Standards (CGRM) in 2006. As part of the three year cycle of reviews the next review will be in July 2009. In order to prepare for this review a plan was developed and implemented in 2008. This plan involved identifying and agreeing the Lead Director for each part of the standards. The process also involved a named member of the CGRM Unit supporting each Lead Director and their associated support staff with the development and implementation of an action plan. The action plan detailed steps that would be taken in order to ensure compliance and improvement against the standards. Where a Director was aiming for level 3 or 4 an evaluation plan was also developed. It was agreed that the Performance Governance Committee (PGC) would oversee the achievement of compliance and improvement and the Head of CGRM has regularly reported the progress to PGC.
In terms of the Clinical Governance and Clinical Effectiveness parts of the standards, the plans and achievement against these have been reported to the Committee at each meeting in 2008.
The progress against the standards was presented to the Board in a seminar in May 2009.
2.6 / Committee Assurance Plan
The work plan was renamed as an Assurance Plan. The Assurance Plan has been updated and version 4 was presented to the Committee in February 2009. The Assurance Plan links with the corporate objectives and risks with areas of assurance that the committee are requiredto consider. There is a requirement for the plan to be refreshedonce the corporate objectives have been approved and the associated risks have been determined. The Assurance Plan still requires improvement in terms of ensuring the plan covers the criteria in the Clinical Governance and Risk Management standards.
2.7 / Clinical Governance Forum
The Clinical Governance Forum has met on 4 occasions in 2008. It is a forum where Sector Clinical Governance Leads, Clinical Governance Coordinators and other relevant stakeholders meet to share best practice, share learning and to problem solve areas of difficulty and concern. The Forum also oversees the Committee Assurance Planand the External Review Database output and progress with compliance with standards. An Annual Report from the Forum was presented to the Committee in August 2008. The format of the Forum was reviewed and adapted so that the meeting was divided into two with the first half being a business meeting where specific items and cross-system issues from the sector reports are explored and the second half being a workshop to explore issues in greater depth. The three workshops have covered the following topics:
  • Transfer of patient information
  • Managed Clinical networks and
  • Evaluation of Sector Clinical Governance Groups.

2.8 / Clinical Governance Evaluation Plan
A number of evaluation activities have been developed and implemented throughout 2008. These have now been drawn together into a Clinical Governance Evaluation Plan. The plan details the activities that have been implemented but also planned for future activities and shows a progressive approach to evaluation.
The Clinical Governance Committee has undertaken a number of development sessions as part of its usual business. The development sessions allow reflective time for the Committee on different chosen aspects of its function. Specific topics are chosen by the Chair, Director of Nursing (responsible for Clinical Governance) and the Head of CGRM Unit. Often the topics have been debated within a Committee session and so have the agreement of the members. The development sessions commence with a refresher on the role of the Committee and what Clinical Governance is about. In 2008 one development session took place in September and the topic chosen was to explore the clinical governance arrangements for redesign and change activities. There was a concern that these activities were standing outside the assurance structures. A couple of planning meetings took place, particularly involving the Director of Planning. Members of example projects were invited, including the Emergency Care project, Intermediate Care and Better Care Without Delay. A successful discussion took place, leading to a recommendation to explore this issue further with NHS Grampian Board. A report was written detailing the findings.
An evaluation exercise took place as there was curiosity around the functioning of the Sector Clinical Governance groups that feed into the Clinical Governance Committee. From attending aClinical Governance group,it was agreed by the Committee that it would be beneficial to attend the other Sector Clinical Governance groups. The Chair of the Clinical Governance Committee, Director of Nursingand Head of CGRM attended the Clinical Governance groups over a 12 month period to observe the workings of the groups.
A framework for the evaluation was developed to aid the observations and questioning but also to ensure consistency. A timetable was produced ensuring that at least 2 of the 3 review panel members were in attendance at each Clinical Governance group. It was agreed that this exercise would be undertaken over a 12 month period. The respective Clinical Governance Lead/Chair of the Sector Clinical Governance group and Clinical Governance Coordinator of each group were informed about the visit date and sent the framework prior to their meeting. They were asked to provide a range of supportive documents such as their Role, Remit and membership of their group, Clinical Governance action plan and previous minutes.
At the group meeting, the review panel observed the activity and asked questions, mainly to clarify points. The panel also answered any questions the group members had, generally concerning organisation wide issues and the panel also provided suggestions for improvement. The huge benefit of visiting the groups meant that benchmarking could take place and any good practice observed could be shared. The Chair of the Clinical Governance group and Clinical Governance Coordinator was sent a draft report, following the visit, for comments. The final report for each group was then distributed.
Following completion of all Clinical Governance group visits, the Clinical Governance Coordinators met with the Head of CGRM to discuss the findings, problem solve and identify potential areas for single and collective group improvement; again sharing areas of good practice. The review process was then reported at the Clinical Governance Committee in February 2009 and the findings were taken to the Clinical Governance Forum in March 2009 for full discussion and sharing of learning. The next step that builds on this exercise consists of the sector groups continuing to use the framework to conducttheir own self assessment and for the review panel to continue to undertake annual group visits. A report was written of this area of evaluation.
2.9 / Clinical Governance and Risk Management Unit
The CGRM Unit was formed following an integration exercise bringing together Clinical Governance, Clinical Effectiveness and Risk Management (including Health and Safety). A Unit work plan was developed and this was refreshed within 2008. Actions relating to clinical governance include:
  1. The development, implementation and monitoring of the Clinical Effectiveness strategy and associated work plan. This has been achieved with the report on progress of the Clinical Effectiveness work plan reported to the Clinical Governance Committee in November 2008. The work plan now ensures that the audit activity covers both national, corporate, sector and emerging priorities. The work plan now for the first time allows greater analysis and prioritisation of the activity. More detail is provided in section 3.1.
  1. A quality assurance process for all audit activity has been developed and implemented. This arose from concerns with the potential to publish reports that may not be fit for purpose and the need to clarify the ownership of the data, findings and report whilst protecting the reputation of NHS Grampian and the CGRM Unit. The quality assurance process aims to prevent this occurrence. The quality concerns have not been repeated since the introduction of the process.
  1. Continuing to work towards the CGRM Standards, to enhance compliance and preparation for the second round of peer review visits.
  1. Continued refinement of the External Review Database where all the external review activity is detailed. The database aids planning of the events and activities but also assists to provide an overview of where NHS Grampian is in relation to compliance with standards and preparation for review visits. The activity is reported at each Clinical Governance Committee and the detail of attainment and progress is discussed at each Clinical Governance Forum meeting.
  1. In 2008 NHS Grampian was subjectedto peer review visits for the following:
Peer review visit / Achievement